coding course syllabus - ophmasters annual sponsored by the florida society of ophthalmology june...

www.ophmasters.com

Sponsored by the Florida Society of Ophthalmology

June 28, 2013

The Breakers | Palm Beach, Florida

SYLLABUSCODING COURSE

Friday, June 28 7:00‒8:00 AM REGISTRATION AND BREAKFAST South Ballroom Foyer 8:00‒10:00 AM Medicare Update

Physician Fee Schedule Changes

ASC Fee Schedule Changes

CPT and ICD-9 Changes QUESTIONS & ANSWERS

10:00‒10:15 AM BREAK West Ballroom Foyer 10:15 AM ‒12:00 PM OIG Work Plan Update

Issues affecting Ophthalmology - New and Ongoing Issues Requiring Special Attention

Modifiers

Surgeries

E&M vs. Eye Codes

Co-Management

QUESTIONS & ANSWERS 12:00‒1:00 PM LUNCH Gold Room 1:00‒2:30 PM ICD-10 Update

Implementation and Training

Coding scenarios Medicare Audit Contractor Concerns CMS Onsite Audits

Clinic

Optical Compliance Issues QUESTIONS & ANSWERS

2:30 PM ADJOURN

AGENDA

TARGET AUDIENCE This program has been designed for physicians, coders, technicians and administrators with a basic understanding of CPT and ICD-9. LEARNING OBJECTIVES Upon completion of the educational activity, participants should be able to:

Upon completion of the educational activity, participants should be able to:

Appropriately select the level of Evaluation and Management or Eye code

Describe updates to the OIG work plan that affect ophthalmology

Implement the CPT and ICD-9 updates into the practice

Recognize changes that will come with the implementation of ICD-10

Discuss Medicare Audit Contractor concerns

Identify practical application techniques to appropriately code for proper reimbursement in all specialties within ophthalmology

ACCREDITATION

CME/CE Credit provided by AKH Inc., Advancing Knowledge in Healthcare

Physicians This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of AKH Inc. and the Florida Society of Ophthalmology. AKH Inc. is accredited by the ACCME to provide continuing medical education for physicians. AKH Inc. designates this live for a maximum of 5.25 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Physician Assistants NCCPA accepts AMA PRA Category 1 Credit™ from organizations accredited by ACCME. Nursing AKH Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s COA. AKH Inc. designates this educational activity for 5.25 contact hours. Accreditation applies solely to educational activities and does not imply approval or endorsement of any commercial product by the ANCC-COA. FL Nursing AKH Inc. is an approved provider for nursing continuing education by the Florida Board of Nursing #50-2560. AKH Inc. designates this educational activity for 5.2 contact hour (.52 CEU). Criteria for Success Statements of credit will be awarded based on the participant's attendance and submission of the activity evaluation form. A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.ophmasters.com/cme. If you have questions about this CME/CE activity, please contact AKH Inc. at [email protected]. Commercial Support No commercial support was received for this course.

OBJECTIVES/ACCREDITATION

http://www.ophmasters.com/cme

mailto:[email protected]

E. Ann Rose Owner/President

Rose and Associates Duncanville, TX

Ann Rose, owner and president of Rose & Associates, is a Medicare reimbursement and compliance consultant who has been associated with the health care industry for 30+ years. Rose & Associates specializes in Medicare coding, billing, documentation, and training for physician practices with medical record auditing being their main focus. Ann’s professional experience began as a member of the Medicare acquisition team at Blue Cross and Blue Shield of Texas shortly after they were awarded the Medicare contract in 1966. She was instrumental in helping develop the HCFA 1500 claim form (now known as the CMS-1500 claim form) and served as a team member in developing the paperless claims processing system known today as electronic billing. For the past 30 years Ann has been devoted to assisting ophthalmologists with coding and reimbursement issues for maintaining compliance with government regulations. She is a member of the American Society of Ophthalmic Administrators (ASOA), the Medical Group Management Association, the American Academy of Ophthalmic Executives (AAOE), and the American Academy of Professional Coders. She is also editor and publisher of The Messenger, a newsletter written and developed specifically for the specialty of ophthalmology and serves on the editorial board of the reimbursement section of Ocular Surgery News.

FACULTY

DISCLOSURE DECLARATION It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The faculty must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Faculty Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other faculty for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review. AKH/FSO planners and reviewers have no relevant financial relationships to disclose. DISCLOSURE OF UNLABELED USE AND INVESTIGATIONAL PRODUCT This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings. DISCLAIMER This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaims responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant's misunderstanding of the content.

FACULTY DISCLOSURES

NAME RELATIONSHIP COMPANY

E. Ann Rose Consultant Heidelberg Engineering, Inc. (2)

PLANNER DISCLOSURES

AKH & FSO Staff/Planners N/A Nothing to disclose

*Compensation Range per Company

1= $0-$1,000 2= $1,001-$10,000

3= $10,001-$50,000

4= ≥$50,001

FACULTY/PLANNERS/STAFF DISCLOSURES

Rose & Associates 1-800-720-9667 1

Medicare Coding Update

2013

Masters in Ophthalmology 2013

Coding Program

Palm Beach, Florida

June 28, 2013

Presented by: E. Ann Rose

Financial Interest

E. Ann Rose is President of Rose & Associates and also provides

consulting services for:

Alcon Surgical, Inc.

Heidelberg Engineering

3

Physician Fee Schedule

• 2013 Physician Fee Schedule Final Rule

– Called for 26.5% reduction in physician fees

• At 11th hour, Congress approved legislation

halting fee cuts through 12/31/13

– SGR remains flawed and ASCRS still fighting

to get payment mechanism changed

• U.S. House of Representatives expected to vote on

proposal for permanent fix by August


4


– Medicare Sequestration (spending) cuts

• 2% cut to Medicare physician payments effective

April 1, 2013

– Also applies to ASC, DME and Incentive bonus payments

• Cuts scheduled to last through 2021

– Co-pays should be collected on actual 2013 fee schedule

allowable, not the 98% payment

– 1.000 GPCI floor extended through 2013

• Good news for physicians practicing in areas with

normally low GPCIs


Code Description %

66982 Complex Cataract w/IOL -21%

66984 Cataract w/IOL -13%

67028 Intravitreal Injection -9%

92235 Fluorescein Angiography - 6%

92286 Endothelial Cell Counts -69%

Procedures with RVU Reductions

• Some fees increased due to RVU changes

• Some fees decreased

5

6


– Survey conducted jointly by ASCRS and ASOA

found time to perform cataract surgery has

dropped 30% in past 8 years

– Also fewer post-op visits performed

• Cataract cuts would have been greater without

survey

• Final conversion factor for 2013 • $34.0230

– Included budget neutrality reduction

– 2012 CF was $34.0376



CPT Code 2012 2013

66170 – Trabeculectomy $1,178.72 $1,238.44

66821 – YAG - Office

66821 – YAG - Facility

$ 326.08

$ 307.70

$ 344.99

$ 325.26

66982 – Complex Ct w/IOL $1,054.48 $ 828.46

66984 – Cataract w/IOL $ 760.74 $ 667.87

67028 – Intravitreal Injection - Office

67028 – Intravitreal Injection - Facility

$ 115.73

$ 104.16

$ 105.13

$ 103.43

67036 – Vitrectomy $ 948.97 $ 990.41

67108 – Repair Detach. Retina $1,589.56 $1,656.58

National Fee Schedule Payment Amounts

Through December 31, 2013

7


CPT Code 2012 2013

92004 - Comp, New patient $144.66 $151.40

92012 - Interm, Est. Patient $ 82.71 $ 87.44

92014 - Comp, Est. Patient $119.81 $126.23

99203 - Detailed, New Patient $105.18 $108.19

99213 – Exp. Prob. Focused, Est. Patient $ 70.46 $ 72.81

99214 – Detailed, Est. Patient $104.16 $106.83

*Comprehensive eye codes still paying more than lower level E&M codes *

99204 - Comp, New Patient $160.66 $164.67



8

9


– Technical component of some diagnostic tests

capped at Outpatient Prospective Payment

System (OPPS) rate

• RUVs for facility applied to office based tests

Code Description

92240 & 92240TC ICG

92250 & 92250TC Fundus photos

92287 & 92287TC Cell counts w/fluorescein


10


– Multiple Procedure Payment Reduction

(MPPR) applied to certain diagnostic tests

• Technical component (-TC modifier) of second and

subsequent tests performed on same patient, same

day will be reduced by 20%

• Physicians should bill as usual

– CMS will automatically make reductions

• CMS will monitor practice patterns to make sure

doctors don’t perform additional tests on different

days just to avoid multiple procedure reduction


Diagnostic Tests Subject to

MPPR

76510 76511 76512 76513 76514 76516 76519

92025 92060 92081 92082 92083 92132 92133

92134 92136 92228 92235 92240 92250 92265

92270 92275 92283 92284 92285 92286

11

12


– PQRS

• Physicians who participate in 2013 will receive

0.5% incentive payment on all allowables

– Except DME (glasses) and drugs

• Glaucoma staging codes removed from Measures

12 and 141

• Measure 124 – Health Information Technology has

been eliminated

• Physicians will now be required to report on

Medicare as Secondary payer claims


13


• Cataract Group Measure reporting lowered to 20

patients instead of 30 this year

– Of these 20 patients, the majority must be Medicare Part

B patients

– Unable to report until second quarter (April, 2013)

• Required patient surveys will be online vs. mail in

surveys

– May be paper if patient requests

• CMS to use 2013 PQRS participation to determine

cuts in future years

14


• Physicians who do not attempt to report in 2013 will

receive a 1.5% reduction in 2015 and a 2%

reduction in 2016 and beyond

– E-Prescribing

• Two new hardship exemptions were added to avoid

the 2013 and 2014 eRx penalties

• Physicians who are receiving the penalty in 2013

will have chance to appeal if they believe their

reductions are in error

15


– Physician Compare Website • Website allows consumers to search for

physicians/providers enrolled in Medicare – Helps consumers make informed choices about

healthcare they receive through Medicare

• Includes basic information – Names, addresses, phone numbers, specialties, clinical

training, genders

– Languages spoken, affiliated hospitals, PAR doctors, etc.

• Now includes physicians who participate in EHR

Incentive program and/or PQRS Group Practice

reporting option


16


– Physician Payment Modifier • Payment to some physicians will be based on

quality and resource use beginning in 2015 and all

physicians in 2017 – Payment value modifier will now only apply to groups of

100 or more instead of original group practices of 25 or

more

– Smaller groups will remain unaffected until 2017

17

ASC Fee Schedule

• 2013 ASC Fee Schedule Includes:

– Consumer Price Index for Urban Consumers

(CPI-U) payment update of 0.6%

– Negative -1.0007% Budget neutrality adjustment

• Societies still working towards getting ASCs paid closer

to what HOPDs are paid

– 2013 ASC conversion factor

• $42.917

18

ASC Fee Schedule

2012 2013

15823 Blepharoplasty $ 964.64 $ 971.02

65755 Keratoplasty $1,530.82 $1,665.08

66821 YAG laser $ 218.59 $ 230.51

66982 Complex cataract $ 964.64 $ 971.02

66984 Cataract with IOL $ 964.64 $ 971.02

67028 Intravitreal Injection $ 59.91 $ 49.33

67036 Vitrectomy $1,655.65 $1,635.00

67108 Retina Detach $1,655.65 $1,635.00

67040 Retina Repair $1,655.65 $1,635.00

0192T Express Shunt $1,681.49 $1,671.00

National ASC Fee Schedule Payment Amounts


19

ASC Fee Schedule

• ASC Supplies – Code V2785, Processing, preserving and

transporting corneal tissue only billable supply • All other supplies included in ASC facility fee

payment

– Pass-through Drugs • Some drugs are considered pass-through drugs

and payable separately to the ASC

• Make sure staff is aware of this and bills Medicare

accordingly

20

ASC Fee Schedule

Code Drug Payment

C9257 Bevacizumab (Avastin – 0.25 mg), compounded $ 1.59

C9298 Ocriplasmin (JETREA – 0.125mg) - (bill 4 units) $ 4,187.00

J0178 Afilbercept (EYLEA) Injection, 1mg (bill 2 units) $ 980.50

J0600 EDTA $ 201.40

J2503 Macugen $ 1,030.43

J2778 Ranibizumab (Lucentis) $ 397.72

J2997 Activase (TPA) $ 52.19

J3300 Triamcinolone – preservative free $ 3.67

J3396 Verteporfin $ 10.30

J7312 Ozurdex – 7 units $ 196.92

J7315 Mitomycin, 0.2 mg (Mitosol) – effective 4-1-13 $ 380.54

J9035 Bevacizumab (Avastin – 10 mg) – If instructed by payer $ 63.56

J9280 Mitomycin – 5 mg $ 22.25

Most Common Ophthalmology ASC Pass-Through Drugs

** Payment amounts updated quarterly

21

ASC Quality Measures

• Quality Measures for ASCs

– Were required to report on 5 measures

• From October 1, 2012 – December 31, 2012

• Reporting required to avoid a 2% payment penalty

in 2014

– Had to report on 50% of claims

– Must also now report measures on claims for

both Medicare primary and secondary

• Effective January 1, 2013


22


– G8908 or G8909 – Patient Burn

– G8910 or G8911 – Patient Fall

– G8912 or G8913 – Wrong site, wrong side, wrong

patient procedure, or wrong implant

– G8914 or G8915 – Hospital transfer/admission

– G8916 or G8917 or G8918 – Prophylactic Intravenous

(IV) antibiotic timing

– G8907 – Patient documented not to have experienced

any of the above events upon discharge

23


– Quality measure reporting for future payments

was effective January 1, 2012

• Had to submit data July 1 – August 15, 2013

– Should be collecting data for two measures

• ASC Measure 6 – Safe surgery checklist use 2012

• ASC Measure 7 – 2012 Volume of Certain

Procedures

– ASC Quality Measures Specifications Manual

available on CMS website

Source: ASCRS 3/30/12

24

ASC Safe Surgery Checklist

• ASC Safe Surgery Checklist – Applies to use during 3 critical peri-operative

periods: • Prior to anesthesia administration

• Prior to skin incision

• Closure of incision and prior to patient leaving OR

– Reporting is done through web-based tool on

QualityNet website • Does facility use safe surgery checklist?

• Must report a YES or a NO


25

ASC Facility Volume Data

• Measure ASC – 7

– ASC Facility “Volume Data”

– All Medicare certified ASCs must report this

measure

– Submission period

• July 1, 2013 – August 15, 2013

• Covering performance period January 1, 2012 –

December 3, 2012

26


– Report through web-based tool on QualityNet

website

• http://www.oqrsupport.com/asc/

– Must report on aggregate count of selected

surgical procedures per category

– Two categories affecting ophthalmology

• Eye

• Skin


Organ System Category Procedure Code

Eye Organ transplant (eye) 65756, V2785

Laser procedure of eye 65855, 66761, 66821

Glaucoma procedure 66170, 66180

Cataract procedures 66982, 66984

Injection of eye 67028, J2778, J3300,

J3396

Retina, macular and

posterior segment

procedures

67041, 67042, 67210,

67228

Repair of surrounding eye

structure

67900, 67904, 67917,

67924

27

http://www.oqrsupport.com/asc/


28


Organ System Category Procedure Code

Skin Skin procedures 11042, 13132,

14040, 14060,

15260, Q4101,

Q4102, Q4106

Repair of surrounding eye structure 15823

Skin procedures 11042, 13132,

14040, 14060,

15260, Q4101,

Q4102, Q4106



CPT Code Changes

30

E&M Codes

• Majority of CPT changes involved

description revisions to E&M services

– Indicate services may now be performed by

“qualified physicians or other qualified health

care professionals”

• Dependent upon each state’s scope-of-practice

laws

• This is different from ancillary staff that works as

“incident” to a physician’s service


31

Muscle Chemodenervation

• Code 64612

– Revised to include the term “unilateral”

– Parenthetical note added

• To report a bilateral procedure, use modifier -50

32

Muscle Chemodenervation

• Code 64615

– New code

– Use to report chemodenervation of muscle(s)

innervated by facial, trigeminal, cervical spinal,

and accessory nerves, bilateral (eg., for

chronic migraine)

• Report only once per session

• Do not report with 64612, 64613, 64614

33

AC Tap

• Code 65805

– Has been deleted

• Code 65800 revised

– Now indicates paracentesis of anterior

chamber of eye (separate procedure); with

removal of aqueous

• Includes note instructing physicians to use code

65800 for paracentesis of anterior chamber with

therapeutic release of aqueous


34

Biopsy of Eyelid

• Code 67810

– Revised to clarify depth and type of biopsy

required for eyelid skin lesions when

malignancy suspected

• Now classified as “incisional” biopsy

– Involves incision of top and bottom layers of lid margin

• Note instructs physicians to now use codes 11100,

11101, 11310-11313 when reporting biopsy of the

skin of eyelid

35

Refraction

• Code 92015

– Revised to include instruction to use code

99174 for instrument based ocular screening

• Code 99174

– Is to be used for vision screening utilizing

autorefractors and photoscreeners or

combination of devices for routine vision

• Often performed at well-child screenings on

children ages 3-6 who can’t read vision charts

36

SCODI

• Code 92132, SCODI, anterior segment

screening

– Includes note instructing physicians to use

code 92286 for billing specular microscopy

and endothelial cell analysis


37

Specular Microscopy

• Code 92286

– Revised to indicate anterior segment “imaging”

with interpretation and report; with specular

microscopy and endothelial cell “analysis”

• Revision required to “revalue” it more appropriately

• Now reflects new technology

– Cell counts, and

– Assessment of the thickness of the cornea and angle of

the iris to determine the presence of glaucoma

38

Monitoring Intraocular Pressure

• Code 0173T

– Monitoring of intraocular pressure during

vitrectomy surgery

– Code has been deleted

39

Insertion of Ocular Telescope

• 0308T – Insertion of ocular telescope

prosthesis including removal of crystalline

lens

– New Category III code effective 7/1/13

• For implantation of prosthetic intraocular telescope

for treatment of central vision loss (bilateral central

scotomas) due to end-stage age-related macular

degeneration (AMD)


40

Insertion of Ocular Telescope

– Not described by any current CPT code

• Involves removal of lens and insertion and

implantation of a telescope into the lens capsule

– No RVUs assigned by Medicare

• Payment will be left up to carrier discretion

– Do not report in conjunction with codes

• 65800-65815, 66020, 66030, 66600-66635, 66761,

66825, 66982-66986, 69990

41

Glaukos I-Stent®

• FDA approved 6/14/12

– Implanted during cataract surgery in adults

with mild to moderate open angle glaucoma

being treated with medications to reduce eye

pressure

• To report use code 0191T – Insertion of anterior

segment aqueous drainage device, without

extraocular reservoir; internal approach

42

Afilbercept (EYLEA™)

• J0178, Injection, 1mg

– New HCPCS code

– Replaces Code Q2046

– Considered ASC pass-through drug

– Bill 2 units


43

JETREA®

• JETREA® (ocriplasmin) – FDA approved October, 2012

• For treatment of symptomatic vitreomacular

adhesion (VMA) – Dx: 379.27

– When performed in office • Bill J3490 or J3590 – 1 unit

– Identify name of drug, dosage and NDC number in item

19 (or EMC equivalent) of CMS claim form

– When performed in ASC • Bill C9298 – 4 units

• Has ASC pass-through status

44

Mitosol

• New HCPCS Code

– J7315, Mitomycin, ophthalmic, 0.2mg

• Antimetabolite indicated as an adjunct to ab

externo glaucoma surgery

• Used to reduce scarring and to treat severe eye

inflammations and some forms of cancer

• Should only be used for Mitosol and should not be

used for compounded mitomycin or other forms of

mitomycin

– ASC pass-through drug effective 4/1/13

45

ICD-9 Changes

• As anticipated there were no changes to

the ICD-9-CM coding manual for 2013

• ICD-10

– Will be implemented on October 1, 2014

– Need to start preparing now for this transition


ASC Conditions for Coverage

Two Issues Remain A Problem In Audits

47

ASC CfCs

• Comprehensive H&P required within 30 days

of admission for all surgeries performed in

ASC • Complete ROS

• Exam of pertinent organ systems (e.g., head, heart,

lung, abdomen, extremities)

• MDM – Must state “patient cleared for surgery in

ambulatory setting”

• Can be performed same day as surgery but before

patient has been prepped for surgery

48

ASC CfCs

• Separate surgical re-assessment day of

surgery • At minimum, exam for any changes in patient’s

condition since H&P performed

• If H&P performed same day, can combine findings

of H&P and Re-assessment

• Discharge order must be signed by

surgeon and timed • Ancillary staff can perform post-surgical

assessment


Additional

Coding & Documentation

Issues

50

One or More Sessions

• Some procedures have the phrase “1 or more

sessions” as part of their CPT description

Laser Procedures

65855 67141 67218

66761 * 67145 67227

66762 67208 67228

67101 67210

67105 67220

* States “per session” to indicate single surgical session with 10 day global

51


• What does “1 or more sessions” mean?

– The intent of the phrase is to include all

sessions in a complete defined treatment

period

• May occur at different encounters but may be

reported only once

– For Medicare purposes, this means the

defined global fee period for the procedure


52


• Note:

– If a new or different condition appears within

the global fee period

• Use appropriate modifier to indicate the treatment

is not part of the original defined treatment series

– Modifier -78 or -79 would apply

53

One or More Stages

• What about the phrase “1 or more stages?”

– CPT uses these phrases interchangeably

– The CPT codes that include the phrase “1 or

more stages” aren’t necessarily “staged”

procedures

• There are very few “staged” procedures in

ophthalmology

– Should report these procedures only once

during global fee period

• 66821, 66840, 67031

54

Bilateral/Unilateral

• Most diagnostic tests are considered

bilateral • Payment includes both eyes

– If CPT description indicates “unilateral or

bilateral,” Medicare inherently pays as a

bilateral service • -52 modifier not required

– If CPT description does not indicate unilateral

or unilateral/bilateral (e.g., 92020, 92060) • Append -52 modifier to indicate only one eye tested


55


• Some tests are unilateral and can be billed

to Medicare “per eye”

– 76512 – Contact B-scan

– 92071 – Fitting of contact lens, ocular disease

– 92072 – Fitting of contact lens, keratoconus

– 92225 – Extended ophthalmoscopy, initial

– 92226 – Extended ophthalmoscopy,

subsequent

56


– 92230 – Fluorescein angioscopy

– 92235 – Fluorescein angiography

– 92240 – ICG

• Diagnostic tests are payable during the global fee period

• No modifier required

• Do not use -25 modifier with diagnostic tests – may cause audit

– Chart must be clear as to who ordered test and who performed the service

57

Test Results

• All test results must be readily available

– In some instances, photos and results of tests

may not be in the paper chart or the EMR

• Sometimes stored digitally

– The medical record must document the

location of the diagnostic test in this case

• Disc C, dated 4/1/13, etc., or

• Notation as to where test result can be found


58

Visual Fields

• Visual Fields – MN for eyelid surgery

– Once with lids taped, and

– Once with lids not taped

• According to CPT Assistant, this is a single

isopter test

– Code 92081 is correct code

– Some payers may permit different codes or

the use of -76 modifier on second line item

• Check with your MAC for specific instructions

59

Interpretation & Report

• There appears to be an increasing lack of

compliance with Interpretation & Report

requirements

• An “interpretation and report” should

address the findings, relevant clinical

issues, and comparative data (when

available) • Source: Medicare Claims Processing Manual, 100-4, 13-§100

60


• At minimum MD should address: – What was seen or not seen but anticipated

• Glaucoma

– What findings suggest as to status of illness • Stable, worsening, improving

– What impact the test results have on treatment • Continue present meds, surgery as indicated, see

Plan, etc.

• Physician must also sign the I&R



Diagnostic Tests Requiring an Interpretation & Report

Corneal Topography 92025 Remote Retinal Imag. 92228

Sensorimotor Exam 92060 Fluoresceins 92230-92240

Visual Fields 92081 - 92083 Fundus Photography 92250

Serial Tonometry 92100 Oculoelectromyog. 92265

SCODI, anterior seg. 92132 Electro-oculography 92270

SCODI, optic nerve 92133 Electro-retinography 92275

SCODI, retina 92134 Dark Adaptation 92284

Prov. test/glaucoma 92140 Ext. Ocular Photo 92285

Ext. Ophthalmoscopy 92225-92226 Cell Counts 92286 -92287

61

62

Submitting Accurate Claims

• Medicare providers are required to protect

the integrity of the Medicare program by:

– Submitting accurate claims;

– Maintaining current knowledge of Medicare

billing policies; and

– Ensuring all documentation required to

support the medical need for the service

rendered is submitted

63

Submitting Accurate Claims

• Medicare requires that an item or service:

– Meets a covered benefit category

– Is not specifically excluded from coverage

– Is reasonable and necessary

• Claims must also be filed in a timely

manner • 12 months or 1 calendar year after the date of

service

• Denial of untimely claims cannot be appealed


64

Medically Unlikely Edits

• MUEs were created to reduce Medicare

paid claims error rates

– Automated pre-payment edits conducted on

submitted claims to prevent inappropriate

payments

• An MUE is the maximum units of service

that would be reported for a single

Medicare patient on a single date of

service

65


• MUEs are adjudicated against each line of

a claim rather than the entire claim

– If service is reported on more than one line,

each line with that same code is adjudicated

against the MUEs

• MACs deny the entire claim if units of

service on a single line exceed the MUEs • Other services on that claim can be appealed

66


• According to CMS anatomic modifiers (-LT,

-RT, E1-E4) on separate lines will permit

payment of claim in excess of MUEs

– Unfortunately, some MACs are denying claims

billed on 2 lines using the anatomical modifiers

• According to the Medicare Claims Processing

Manual, bilateral procedures are supposed to be

billed on one line item using the -50 modifier

• Bill with “1” unit and increase your charge


67

Reasons for Claim Denials

• First Coast indicates the following as top

reasons for claim denials

– Diagnosis is inconsistent with procedure

– Duplicate claim or service

– Timely filing

– Service covered by another payer

– Medicare coverage terminated after expenses

incurred

68


– Routine examinations and related services

– Service deemed not medically necessary

– Inappropriate or invalid place of service

– Non-covered service submitted

– Benefit for service is included in

payment/allowance for another service or

procedure that has already been paid

69


– Medicare does not pay for this many services

or supplies

– Payment adjusted when performed or billed by

this type of provider

– Services are bundled and not payable

separately

– Provider not eligible to provide service or

procedure on this date


70


– Patient is enrolled in a hospice or SNF

• Go to FCO website and see how to avoid

these denials • http://medicare.fcso.com/Inquiries_and_denials/156

449.asp

• Conduct internal audits and in-services on

denials

• Continued errors will cause unwanted

scrutiny by CMS

71

Steps to Improve Revenue

• Co-pays, co-insurance and deductibles

– These should be collected from the patient at

the time of service

– Permits timely filing of claims

• Working claim denials

– Denials should be worked on a daily basis

– Find the reason for the denials and fix it right

away

72


• Internal audits

– Revenue can be lost if there is no one auditing

codes and claims

– Regular internal audits will assist in submitting

clean and accurate claims

– Run reports monthly and audit your most

utilized codes and modifiers

http://medicare.fcso.com/Inquiries_and_denials/156449.asp

http://medicare.fcso.com/Inquiries_and_denials/156449.asp


73


• Keep staff well trained – Undertrained staff can be the result of

significant lost revenue

– Provide staff with an avenue to stay up-to-date

on Medicare guidelines

– Make sure staff has access to needed coding

manuals • CPT

• ICD-9 and ICD-10

• CCI edits

2013 OIG Work Plan

Update

Includes new and ongoing issues affecting Ophthalmology


76

Medicare On-site Visits

• CMS conducting on-site inspections of

providers/suppliers to verify enrollment

– Mandated by Provider Enrollment, Chain, and

Ownership System (PECOS)

• OIG to determine how often these on-site

visits occur

– Prior reviews found that some suppliers did

not even maintain physical facilities

77

Medicare On-site Visits

• Avoiding Scrutiny

– Physician clinics most likely not an issue

– Optical shops

• Revisit DME Supplier Manual requirements

– Post hours of operation

– Provide patient access to Supplier Standards

– Maintain Rx in optical shop files

– Maintain Proof of Delivery of glasses

– Have complaint resolution protocol

– Etc.

78

EHR Audits

• Providers who received EHR bonuses are

being audited

• Documentation requested includes:

– EHR is certified

– Claims meet objective and measures

– ER admissions

• Documentation must be sent within 2

weeks of receipt of request


79

Ophthalmology Services

• 2011 claims being reviewed by OIG to

identify questionable billing for services

performed by ophthalmologists

– Will also look at geographic locations of

providers exhibiting questionable billing

• In 2010, Medicare allowed over $6.8 billion

for services provided by ophthalmologists

80

Ophthalmology Services


– Nothing you can do about 2011 claims

– Ensure 2013 claims are billed correctly

• Keep billing staff up-to-date on current guidelines

• Conduct internal audits on regular basis

• Work claim denials on a daily basis – fix problems

immediately

• Consider having external audit conducted on an

annual or semi-annual basis

81

Use of G Modifiers

• OIG to determine to what extent CMS

improperly paid claims from 2002-2011

billed with modifiers

– Specifically modifiers -GA, -GX, -GY, -GZ

• Considerable overpayments identified

– Amounted to $4 million in potentially

inappropriate payments


82

Use of G Modifiers


– Review the use of “G” modifiers

• -GA and -GZ should be used on claims you expect

Medicare to deny as not reasonable and necessary

• -GA modifier

– Test or procedure not covered for a particular diagnosis

for example

• -GZ modifier

– Indicates service is non-covered but you do not intend to

bill patient

83

Use of G Modifiers

• Modifiers -GX or -GY are used for statutorily

excluded services

• -GX modifier

– Lets Medicare know a voluntary notice of liability (ABN)

was provided

• -GY modifier

– Indicates service excluded and no ABN needed

84

Error-Prone Doctors

• OIG continues to review claims submitted

by error-prone providers

– Will request refunds on projected

overpayments using Comprehensive Error

Rate Testing (CERT) audit data


– Work claim denials on a daily basis

• Fix errors immediately


85

High Cumulative Payments

• OIG to identify providers with unusually

high cumulative payments over a specified

period • According to OIG audits unusually high Medicare

payments may indicate incorrect billing or fraud and

abuse


– Conduct periodic audits on higher billed

services for accuracy of coding

86

ASC Payment System

• OIG continues to review appropriateness

of payment methodology for setting ASC

fees

– Will also determine if payment differences

exist for ASC and HOPD claims for same

procedures performed in both settings


– No action required

87

ASC Safety/Quality Issues

• OIG will continue to review the safety and

quality of care for patients having surgery

in ASCs and HOPDs

– Will identify adverse events


– ASCs should be reporting adverse events

through ASC Quality Measure Reporting


88

Assignment Rules

• OIG looking to see if beneficiaries are

inappropriately billed in excess of Medicare

allowed amounts

– PAR doctors agree to accept assignment on

all services billed to Medicare

• Can only collect 20% coinsurance and deductible


– Make sure patients are not inadvertently being

overcharged for your services

89

Incident-To Services

• OIG to review claims to see if incident-to

services had higher error rate than non-

incident-to services – Ancillary staff services performed incident-to a

physician’s service might include: • IOP check, bandage change, help with meds, etc.


– Make sure ancillary staff performing incident-

to services are well trained

90

Place of Service

• OIG still looking at ASC and HOPD claims

to see if correct place of service used

– When incorrectly coded as office, physician

receives higher Medicare payment


– If service performed inside ASC firewall, place

of service must be ASC, not office

– If you see inpatients in your office, must code

POS as inpatient, not office


91

E&M Services

• OIG looking at extent of inappropriate payments

for E&M services

– Also increased frequency of medical records

with identical documentation


– Conduct internal and external audits of office

visits on a regular basis

• Hold in service training for aberrant physicians

92

Modifiers

• OIG still looking at global fee modifiers

• Global surgery payment includes related pre-

operative and post-operative office visits provided

in global surgery period

– Prior OIG work shows that improper use of

modifiers during global fee period resulted in

inappropriate payments

93

Modifiers


– Modifier -24

• Before appending modifier -24 ask this question:

– Would patient have needed service had the surgery not

been performed?

• If answer is no, then don’t bill with -24 modifier

– If patient presents for post-op follow-up and

exam includes evaluation of surgical eye

• Exam will most likely be denied in post-pay audit


Issues Requiring Special

Attention

Modifiers

96

Who’s Auditing Modifiers?

• Medicare Administrative Contractors (MACs)

– CERT audits • Performed post-operatively on a statistically-valid

random sample of Medicare claims – Look to see if claims were paid properly

– Claims are subject to potential postpayment denials,

payment adjustments, or other legal actions

• CERT audit results are also shared with RAC

auditors if audits indicate billing patterns that may

suggest fraud – Have identified high number of office visits billed at

comprehensive level

– Some included modifiers -24 and -25


97


• Recovery Audit Contractors (RACs) – There are two types of RAC audits

• Paid claims data – No medical record required

• Medical record audit – Will receive letter requesting copies of charts

– Most practices only audited on paid claim data

not record request

– RACs can go back 3 years to audit • Medicare contractors only 1 year unless fraud

suspected

98


• Office of Inspector General (OIG) – The big daddy of auditors

• Looking at global fee modifiers for several years

now – Particularly interested in modifiers -24, -25 and -59

• Previous audits showed significant error rates for

modifiers -25 and -59

• 35% of modifier -25 did not meet requirements – Resulted in $538 million in improper payment

• 40% of modifier -59 did not meet requirements – Resulted in $59 million in improper payments

99

Global Fee Periods

• Before using modifiers, it’s important to

understand global fee concept

• A global fee is defined as:

– A single fee that involves all necessary

services normally furnished by the surgeon

before, during and after the surgical procedure


100

Global Fee Periods

• There are two types of global fee periods –

Minor and Major

– Minor Surgery - “0” day global fee period

• Includes day of surgery only for such procedures

as:

– Biopsies

– A/C tap

– Subconjunctival or Sub-Tenon injections

– Trichiasis by forceps

101

Global Fee Periods

– Minor Surgery - “10” day global fee period

• Includes day of surgery and 10 days following

surgery such as:

– Punctum plug insertions

– Lesion removals

– Epilation trichiasis

– Argon Laser Trabeculoplasty (ALT) - code 65855

– Laser Iridotomy/Iridectomy - code 66761

102

Global Fee Periods

– Major Surgery – 90 day global fee period

• Includes day before surgery, day of surgery, and 90

days following surgery for such procedures as:

– Blepharoplasty

– Ectropion/Entropion repair

– Cataracts

– YAG laser capsulotomy

– Retinal Detachments/Repairs

– Laser procedures (except ALT & laser

iridotomy/iridectomy)

– Vitrectomy

– Glaucoma filter procedures


103

Global Fee Periods

• Medicare considers all doctors in a group

practice to be considered the “same”

doctor with regard to providing post-

operative care

– Patient develops edema following cataract

surgery and sent to retina doctor to treat

• Office visit not billable

• Treatment billable if it requires a “return to OR” (-78

modifier)

104

Why Modifiers Are Required

• Modifiers are:

– Integral part of billing process

• Let Medicare know special circumstance has

occurred

• Permit services to be paid that would otherwise be

denied

• Modifiers are needed to:

– Ensure proper payment

– Prevent excessive denials and lost revenue

Modifiers Under Scrutiny


106

Modifier -25

• Significant, separately identifiable service

by same physician on day of minor

procedure

– Exam is not just incidental to surgery

• Modifier -25 indicates office visit is above and

beyond usual pre- and post-operative care

associated with minor procedure

– Should be appended to office visit not minor

procedure code or diagnostic test

107

Modifier -25

– Cannot be used as decision for surgery like

modifier -57

• Most common misconception among doctors

– Exam must be substantial, distinct and unique

and able to stand alone

• Take the exam for the minor surgery or injection out

of the mix for a minute

• Do you have anything left?

– If yes, append the -25 modifier

– If no, office visit should not be billed

108

Modifier -25

• Example:

– Patient presents with complaint of pain and

foreign body sensation after being hit in eye

with tree limb

– Complete exam performed to determine extent of injury and cause of pain – FB removed

– Modifier -25 is appropriate • If only slit lamp performed and foreign body

removed without complete eye exam, office visit not billable


109

Modifier -25

• Retinal injections are particular area of

concern

– Huge increase in intravitreal injection visits

billed with -25 modifier

– Modifier -25 should always be the exception

not the rule

• Does not have to be a different diagnosis

• Must address more than the decision for surgery

that extends above and beyond pre-operative care

110

Modifier -25

• Example:

– Patient presents with neovascular AMD in left

eye status-post Lucentis injection 4 weeks ago

• States vision improved in left eye but now has

decreased vision and distortion in right eye

– Exam shows new AMD in right eye

• Left eye has active AMD

• Pt treated with Lucentis in RT eye – Told to return

for Lucentis in LT eye in 3 days

– Modifier -25 is appropriate

111

Modifier -25

• Example:

– Patient presents for injection #4 in left eye

• States vision not that great but stable

– Surgeon recommends intravitreal injection

today and FU in 2 months with OCT

• No new complaints or medical necessity to perform

exam over and above need for injection

– Modifier -25 is not appropriate


112

Modifier -25

• Example: – Patient w/hypertension, high cholesterol, and history

of heavy smoking presents for FU of Drusen, OD • Patient complains of reduced ability to read

– Exam identifies AMD, OU and hypertensive retinopathy

with appearance of some occlusion

• OU IVFA and OCT shows exudative AMD OS and

nonexudative AMD, OD

– Doctor recommends Avastin injection OS/FU in 4 wks

– Modifier -25 is appropriate • Multiple conditions and multiple eyes being addressed

113

Modifier -25

• In Summary

– Modifier requires exam over and above usual

pre- and post-operative care associated with

procedure

– Use with office visits only

• Not on tests or surgeries

– Procedure must have a “0” or “10” day global

fee period

– May sometimes need to append both -24 and

-25 modifiers

114

Modifier -25

– Only applies to the physician performing the

surgery

– Does not have to be used with new patients

• New patient exams are exempt from global fee

– Can’t use on re-evaluations when patient

asked to return for the surgery and no new

complaints

– Diagnosis does not have to be different

• But, different diagnosis, in itself, may not warrant

the use of modifier -25 either


115

Modifier -59

• Procedure or service is distinct or

independent from other services performed

on the same day

– Used to unbundle codes included in the

Correct Coding Initiative (CCI) edits

– Distinguishes procedures not normally

reported together:

• Different session or encounter

• Different procedure or surgery

– Separate excision/incision

116

Modifier -59

• Different site or organ system

– Anterior segment vs. posterior segment

• Separate lesion

• Separate injury

– Modifier -59 should not be appended to office

visits

– Should only append modifier -59 on second

and subsequent procedures performed at the

same session

117

Modifier -59

• Documentation in the medical record must

satisfy the CCI bundling criteria

– If not, claim will be denied in post-pay audit

and refund requested

• One of the biggest misuses of modifier -59

is related to the definition of “different

procedure or surgery”


118

Modifier -59

– CCI instructions clearly indicate that the two

procedures/surgeries cannot be reported

together if performed at the same anatomic

site and same patient encounter

• Anterior vs. Posterior segment

• Different diagnosis is also not deciding factor

119

Modifier -59

• Example: – New patient presents with cataracts,

glaucoma, and high IOP • Surgeon performs peripheral iridotomy (66761) to

lower pressure at that visit

– Patient returns in afternoon with no

improvement • Surgeon decides to remove cataract (66984) to aid

in lowering intraocular pressure

– Modifier -59 is appropriate • Different procedure/session

120

Modifier -59

• Example:

– During cataract surgery (66984), vitreous

prolapse occurred

• Anterior vitrectomy (67010) performed to take care

of hemorrhage


• Since both the cataract and the anterior vitrectomy

were performed in the same segment of the eye,

unbundling would not be appropriate

– Diagnosis alone does not justify unbundling


121

Modifier -59

• Modifier should never be used just to

obtain payment for bundled procedures

– Have staff (and doctors) read CCI Manual

Introduction

• Section on ophthalmology

• Amazed at what they may learn

• Staff needs access to CCI bundles

– Should verify if services are bundled or not

before submitting claim

Other Modifiers Needing

Attention

123

Modifier -24

• Unrelated service during post-op period

– In other words, office visit is not related to:

• Underlying condition for which surgery was

performed, or

• Surgical episode itself such as complications

– Before appending modifier -24 should always

ask:

• Would patient have needed exam if the surgery

had not been performed

– If answer is yes, then modifier -24 is appropriate


124

Modifier -24

• Do not use modifier -24 for office visits

related to complications of surgery

– Post-op follow-up visits

– Second eye surgery exam in global period if

visit addresses surgical eye and no new

complaints in fellow eye

– Known complications of surgery such as

• Endophthalmitis

• Conjunctivitis

125

Modifier -24

• Example: – Surgery patient returns in global fee period of

cataract surgery for scheduled 3-month

glaucoma follow-up

– Modifier -24 is appropriate • Glaucoma diagnosis unrelated to cataract surgery

• Make sure CC does not state “here for PO exam”

• Diagnosis must be glaucoma, not cataract – This is a common billing error

• Billers can’t bill appropriately if chart not correct

126

Modifier -24

• Example:

– Patient presents during global fee period with

decreased vision in the surgical eye so severe

it’s affecting their ability to function

• Exam identifies severe posterior capsular

opacification and YAG laser surgery recommended

same day


• PCO is known complication of cataract surgery

– If patient outside global fee period, then -57 modifier

would apply


127

Modifier -58

• Staged or related procedure by same physician

during post-op period

• More extensive than original procedure

• Planned procedure documented prospectively at time of

original procedure

• Therapy following a surgical procedure

• Injection given in the lane

– Does not apply to laser procedures indicating “per

session” or “one or more sessions”

– Not to be used for treatments requiring “return

to OR”

128

Modifier -58

• Physician does not have to specifically

state planned stages

– Can be within stated Plan of Care or can be

implied

• Executing a more extensive procedure because

original procedure did not achieve desired outcome

– Ask these questions:

• Is original condition being treated?

• Is subsequent procedure more extensive than the

first?

129

Modifier -58

• Is something being done to “finish” what was

started with the prior procedure?

• Is procedure being done to facilitate therapy, or is it

therapy following a prior procedure?

– If answer is “yes” to any of these questions,

modifier -58 is appropriate


130

Modifier -58

• Example:

– Physician excises right lower lid lesion

• Pathology report indicates additional tissue should

be removed

– During global fee period (day 8), larger

excision performed with skin graft

• Would be considered “staged” procedure

• Correct billing

– 14060-E2-58

131

Modifier -58

• Other examples:

– Trabeculectomy following a failed ALT or

iridotomy/iridectomy

– Scleral buckle following a pneumatic

retinopexy

– 5-FU injections following trabeculectomy

– Retina injections following retina surgery for

same diagnosis

Surgeries Requiring

Special Attention


133

Cataract

• Code 66984 – BCVA 20/40 with or without glare

• If glare used to document surgery, must have glare

complaint

– Lifestyle impairment

– Other indications if BCVA not met: • Anisometropia after first eye surgery

• Phacomorphic glaucoma

• Phacolytic glaucoma

• Retina disease that requires clear media

134

Cataract

• Second eye surgery

– Bilateral surgery not recommended

– Interval between eyes should be based on:

• Patient able to provide informed consent for

surgery on second eye after evaluating visual

results of first eye surgery

• Adequate time has passed to detect and treat

complications following first eye surgery

• First eye is healed and stable and patient not at risk

of injury due to functional impairment

135

Complex Cataract Surgery

• Code: 66982

• To be used for management of complicated

cases due to:

– Previous trauma

– Concurrent disease states

– Congenital abnormalities

• Not intended for mishaps during regular

cataract surgery


136

Complex Cataract Surgery

• OP report must address device or special technique used – Iris expansion device

– Suture support of IOL

– Endocapsular rings (weak zonules)

– Use of dye for visualization

– Posterior capsulorrhexis • Tear in posterior capsule does not count

– Pediatric cataract

** Check LCDs for specific billing instructions

137

66982 - Limitations

• CMS advises that 66982 should not be used for:

– Vitrectomy required during surgery

– Posterior capsule tear

– Piggyback IOL

– Trabeculectomy

– Loose zonules

– Intraocular bleeding

– Vitreous prolapse

– Dislocated IOL in the bag

– Extracapsular–spontaneous expulsion

– Wound leak or burn

138

Vitrectomy w/Cataract Surgery

• Code: 67010 – Subtotal vitrectomy

• Bundled with cataract surgery

• Can no longer unbundle using -59 modifier

– Must be performed at different session or in

different segment of eye

• Anterior vs. posterior

– Diagnosis alone no longer reason to unbundle

• Vitreous prolapse


139

Femtosecond Laser

• CMS FS laser guidance

– Released November 16, 2012

– Refractive imaging component of FS laser

performed on premium AC-IOL and PC-IOL

cataract patients before surgery has begun is

non-covered service

• Can bill patient

140

Femtosecond Laser

– CMS does not permit physicians to bill the FS

laser refractive imaging services when a

conventional IOL is used

• Using FS laser on conventional IOL patients (but

not charging for the use of FS laser) should be rare

and performed only on a non-routine, limited basis

– FS laser astigmatic keratometry (LRI or CRI)

performed at same time as conventional IOL

surgery

• May be billed to patient

141

YAG Laser Capsulotomy

• If 66821 performed within 4 months of

cataract surgery, must document: – Patient is experiencing symptoms of blurred

vision, visual distortion, and/or glare with

associated functional lifestyle impairments

– BCVA 20/30 or worse • 20/25 if performed to assist in dx and treatment of

retinal detachment

– Glare test or contrast sensitivity resulting in

decreased visual acuity by 2 lines


142

YAG Laser Capsulotomy

– YAG laser may also be performed to assist in

diagnosis and treatment of:

• Macular disease

• Diabetic retinopathy

• To evaluate optic nerve head

• Diagnosis posterior pole tumors

• Retinal detachment

• YAG is expected to be performed only

once per lifetime per patient (Florida)

Source: First Coast LCD for YAG Laser Capsulotomy

143

Amniotic Membrane

• Code 65778

– Placement of amniotic membrane on the

ocular surface for wound healing; self-

retaining (eg, ProKera)

• Code 65779

– ……….single layer, sutured

• Used for wound repair and healing

– Both have 10 day global fee periods

Amniotic Membrane

CPT Code In Office In Facility

65778 - Placement of amniotic

membrane on the ocular surface for

wound healing; self-retaining

$1,469.45

$ 73.83

65779 - Placement of amniotic

membrane on the ocular surface for

wound healing; single layer,

sutured

$1,291.85

$ 293.96

2013 National Fee Schedule Amounts

144


145

Amniotic Membrane

• Clinical example – Code 65778, self-

retaining – 67-year old male presented with progressive loss of

vision, severe pain, and light sensitivity in right eye

immediately after a chemical burn injury

• Patient has severe ocular inflammation and large

corneal epithelial defect

• Topical and systemic medications failed to relieve

symptoms from lack of corneal healing after 1 week

• A self-retaining amniotic membrane device placed on

corneal surface

146

Amniotic Membrane

• Clinical example – Code 65779, single

layer, sutured

– 70-year old woman presented with decreased vision,

photophobia, and irritation in right eye for 3 weeks

• Patient diagnosed with bacterial keratitis and treated

with topical antibiotics

• Frequent lubrication and bandage contact lens applied

for 5 days with no improvement

• An amniotic membrane for healing is applied and

sutured in place

147

Amniotic Membrane

• Amniotic membrane applied with glue must

be billed with code 66999 per CPT

• Codes 65778 and 65779 not billable with

codes: • 65420, Pterygium removal (CCI)

• 65426, Pterygium removal with autograft (CCI)

• 65430, Corneal scraping (CPT)

• 65435, Removal of epithelium (CPT)

• 65780, Ocular surface reconstruction (CPT)

• Keratoplasty procedures


148

Amniotic Membrane

• 65780 – Ocular reconstruction, multiple

layers

– Usually done for corneal defects such as

burns, scarring, thinning, ulcer, and perforation

• Necrotic epithelium is usually debrided first

• AMT is trimmed and sutured into place

• Additional layers of AMT are placed until all areas

or defect are repaired and in line with surrounding

normal thickness corneal tissue

149

Amniotic Membrane

• Amniotic membrane tissue cost

– Built into physician’s payment when performed

in office

– When performed in surgery center, ASC is

responsible for cost of AMT

• 2013 ASC fee schedule does not have payment

amount for code 65779 (Sutured)

– Presume if paid, it includes cost of tissue

E&M vs. Eye Codes


151

Eye Codes or E&M Codes?

• Ophthalmology and Optometry still only

specialty who has choice of using both

sets of codes

• Eye codes require a lot less documentation

• Eye codes pay more

Documenting Exams

Eye Codes Ocular History, CC

8 -10 Exam elements

Dilation Performed

Treatment Program Initiated Only need 1 Dx and

1 Mgmt option

Can be Rx for new glasses, dx test, recommend surgery, etc.

E&M Codes Complete History Ext. HPI, Complete

ROS & PFSH

All 13 Exam Elements

Dilation Performed

Medical Decision Multiple DX/MO (5-6)

Moderate amount of data

Moderate to High Risk

Comprehensive Exam

152

Documenting Exams

Eye Codes Brief Ocular History,

CC

3-7 Exam Elements

Dilation Not Required

No Initiation of Treatment Program Required

Only need 1 Dx

E&M Codes Expanded Problem

Focused History Brief HPI, Pertinent

ROS

6-8 Exam Elements

Dilation Not Required

Medical Decision Limited DX/MO (3-4)

Limited amount of data to be reviewed

Low Risk - requires minimal treatment plan

Intermediate Exam

153


Eye Codes vs. E&M Codes

CPT Code 2012 2013

92004 - Comp, New patient $144.66 $151.40

92012 - Interm, Est. Patient $ 82.71 $ 87.44

92014 - Comp, Est. Patient $119.81 $126.23

99203 - Detailed, New Patient $105.18 $108.19

99213 – Exp. Prob. Focused, Est. Patient $ 70.46 $ 72.81

99214 – Detailed, Est. Patient $104.16 $106.83

*Comprehensive eye codes still paying more than lower level E&M codes *

99204 - Comp, New Patient $160.66 $164.67



154

155


• To bill an eye code most Medicare

contractors expect to see performance of

at least:

– 1 element of slit lamp, and

– 1 element of the fundus (dilated or not)

• If not performed, bill E/M code

• Comprehensive eye exam requires dilation

and initiation of diagnostic or therapeutic

treatment program

156


• Remember……..coverage of eye exam

based on the purpose of exam, not on

findings

• Without complaint, exam not covered even

though doctor finds pathological condition

– Must always ask: Why is the patient here

today? • Found in Chief Complaint or Plan of previous visit

– Can be new complaint/symptom or previously diagnosed

condition


Co-Management

158

Co-Management

• Surgeon should forward a copy of patient’s

signed transfer of care form indicating

desire to be co-managed

– Copy of form must be maintained in both the

surgeon’s file and the co-manager’s file

• This is mandated by CMS

• Make sure you have a copy of this Transfer

of Care form in your files

159

Co-Management

• Per CMS, decision to co-manage can only

be made between surgeon and patient

– No pre-arranged date of transfer with co-

manager

• Co-manager cannot submit claim until

he/she first sees the patient

– Can bill from date patient was transferred

even if patient not seen for 3 weeks


160

Co-Management

• Surgeon bills surgical code and -54

modifier (e.g., 66984-54)

• Co-manager bills surgical code and -55

modifier when transfer of care has

occurred (e.g., 66984-55)

– Date of service must be date of surgery

– Item 19 must contain date care assumed and

date care relinquished

161

Co-Management

24a (Dates of Service) 24d (Procedure/Mod) 24g (Units)

03/01/12 66984-54LT 1

03/01/12 66984-55LT 1

Item 19

LT EYE Assumed care 03/01; Relinquished care 03/17; Total Days 17

-Surgery performed on 03/01/12

- Follow-up care provided through 03/17/12

Note: Some Medicare contractors require number of post-op days in 24G

Ophthalmologist performing surgery and portion of follow-up care

162

Co-Management

24a (Dates of Service) 24d (Procedure/Mod) 24g (Units)

03/01/12 66984-55LT 1

Item 19

LT EYE Assumed care 03/18; Relinquished care 05/29; Total days 73

-Surgery performed on 03/01/12

- Follow-up care provided through 03/17/12 by surgeon

Note: Some Medicare contractors require number of post-op days in 24G

Optometrist or other MD providing portion of follow-up care


LUNCH

12:00 – 1:00 PM

ICD-10 Update

165

ICD-10 Implementation

• October 1, 2014 – go live date – Per CMS – implementation date is firm and

not subject to change • There will be no delays

• There will be no grace period

• ICD-10 not accepted prior to 10/1/14

• ICD-9 diagnosis not accepted on or after

10/1/14

• Planning must start now!!


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Background

• ICD-9 is current diagnosis code set used in

the U.S.

– ICD-9 has outgrown level of specificity

– No longer reflects advances in medical

treatment

• Very few “unassigned” codes remain in

ICD-9 for new diagnoses

– Many codes don’t accurately describe the

diagnosis they are assigned to represent

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Background

• ICD-10 will be new diagnosis code set

effective October 1, 2014 • Change mandated by HIPAA

• ICD-10 required major computer system

overhaul to permit billing of new codes

electronically • Current Version 4010 was converted to new

Version 5010

• Allows computers to be able to transmit new

diagnosis codes

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Who’s Affected?

• Who does it affect?

– All Healthcare

• Providers (including nurses & technicians)

• Payers

• Software vendors

• Clearinghouses

• Third-party billers


ICD-10 Differences

Differences ICD-9-CM ICD-10-CM

3 - 5 Characters 3 - 7 Characters

All Characters are Numeric

No laterality

Character 1 is alpha (A-Z, not case sensitive)

Character 2 is numeric

Characters 3-7 are alpha or numeric

Laterality

Supplemental chapters:

Alpha and numeric characters

-----

366.22 - Total Traumatic Cataract H26.131 - Total Traumatic Cataract, Right Eye

H26.132 - Total Traumatic Cataract, Left Eye

H26.133 - Total Traumatic Cataract, Bilateral Eye

H26.139 - Total Traumatic Cataract, Unspecified eye

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ICD-10 Differences

ICD-10 Features

Combination Codes Expanded Ambulatory and managed

Care Encounter Details

Added Laterality Timeframes Added

Episodes of Care Added External Cause Codes – no longer

supplementary classification

Expanded codes (diabetes, post-

operative complications) Greater Specificity

Addition of Placeholder “X” – allows for

future expansion Enhanced Quality Reporting

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171

Documentation

• ICD-10 will require more (or improved)

chart documentation

– Has more unique, precise diagnosis codes

• Substantiates medical necessity

– ICD-10 will impact how you do your job

• How you deal with patients

– More questions specific to patient’s complaint or condition

• How you interact with staff

– ICD-10 will require more specificity


172

Documentation

• Documentation becomes critical with

trauma or injuries

– You may need to ask more questions specific

to the patient’s complaint

• What were you doing at the time of the injury?

• Where were you?

• Was this the first injury of this type?

173

Documentation

• Will be required to collect more information

in more detail when documenting chart • Will permit coders to select the right ICD-10 for

symptom, disease, or provided service

• In the past, diagnoses were general

– In ICD-10, there’s a diagnosis for just about

everything

• If chart not documented properly, could lead to

denials

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Documentation

• New documentation to consider

– Laterality plays a big part in ICD-10

• Assessment must be specific to each eye or each

eyelid

– Specificity is more important than ever

• Impression must be as specific as it can be for that

particular complaint or condition

– Particularly important for injuries

– Manifestation is critical where applicable

• Must list disease and manifestation


Documentation

Documentation Differences

Current New

Chalazion OS Chalazion LLL

Cataract NS cataract, OS, floppy iris syndrome

CME CME OS after cataract surgery

Eyelid laceration Laceration, left eyelid, hit in eye with

tree branch

Diabetic Type II diabetes using insulin

Myopia Myopia OU; regular astigmatism OD

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Documentation

Documentation Differences

Current New

Corneal Foreign body

FB in cornea, OD, initial encounter,

subsequent encounter, or sequela

(condition that is consequence of

previous disease or injury)

Ptosis Mechanical ptosis OU

BDR, OU Type II diabetes w/mild NPDR w/o

macular edema; on insulin

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Documentation

• Glaucoma – Must assign as many codes from Glaucoma

category H40 as needed to identify type of

glaucoma, the affected eye, and the glaucoma

stage • Expanded chart documentation will be required

– In some cases, even laterally will apply

• Nurses/technicians/physicians will need to be more

specific particularly as it relates to glaucoma stage – Coder won’t be able to code claim unless chart is properly

documented


178

Documentation

• Cataract

– Some descriptors are different requiring better

chart documentation

• Age-related cataract

– Senile

• Age-related nuclear cataract

– Cataracta brunescens/nuclear sclerosis cataract

• Complicated cataract

– Cataract with neovascularization

179

Documentation

• Diabetes

– 5 Categories in ICD-10

• E08 – Diabetes mellitus due to underlying condition

• E09 – Drug or chemical induced diabetes mellitus

• E10 – Type 1 diabetes mellitus

• E11 – Type 2 diabetes mellitus

• E13 – Other specified diabetes mellitus

– Chart documentation will have to be specific to

these categories

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Documentation

– Combination codes will be important

• Three character category shows type of diabetes

• Fourth character shows underlying conditions with

specific complications

• Fifth character defines specific manifestation

– Diabetic retinopathy

• Nonproliferative: mild/moderate/severe

• Proliferative & unspecified

• With/without macular edema

– Diabetic cataract


TRAINING

182

Training

• Training should focus heavily on clinical

documentation excellence

• Need to correctly and sufficiently provide clinical

details to support coding in ICD-10

– Will be critical in conversion process to avoid

claim denials

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Training

• ICD-10 will require more engagement with

physician

– Physician input may be key to proper

documentation

– Suggest physicians/nurses/technicians get

same training at same time

• That way everyone will be on board with same

information


184

Training

• Prepare listing of the most frequent

conditions treated with ICD-9 codes

– Compare chart documentation to

corresponding ICD-10 codes

• Does documentation allow selection of ICD-10

code at highest level of specificity?

• If yes, move on to next code.

• If not, discuss with doctors and allied staff what

documentation will help code that level of service in

the new ICD-10 codes

185

Training

– Train, train, and re-train on the new ICD-10

codes

• Discuss how your chart documentation will be

impacted

• Additional information that may be required

– Train on additional codes that may be required

for specific conditions

• Diabetes

• Glaucoma stage diagnoses

• Type of injury or where it occurred

186

Training

• Time needed to train personnel

– Initially, 4 to 10 hours recommended

– Other studies suggest:

• 16 hours for experienced coding

• 24 hours for less experienced staff

• Learning curve might not be as steep for

ophthalmology

• Limited number of codes to deal with


187

Training

• May want to take refresher on-line

anatomy course

– Eye anatomy becomes important in ICD-10

• Is not required in ICD-9

• Understanding the differences between

ICD-9 and ICD-10 will be key

– Also the impact it will have on the practice

188

Training

• Staff training crucial to successful transition

– The train has left the station

• No time to put it off

– Need to get involved in the process now

• Taking baby steps a little each month is better than

no progress at all

Case Scenarios


190

Case Scenario

• A 68-year old male patient experiences

sudden vision loss with the sensation of a

veil over his right eye

• Seen by ophthalmologist the same day

• Ophthalmologist examines patient and diagnoses

him with proliferative vitreo-retinopathy with retinal

detachment

– Patient is scheduled for laser therapy to be performed

that afternoon

191

Case Scenario

• Alphabetic index:

• Detachment retina serous traction

H33.4-

• Tabular list:

• H33.4 Traction detachment of the retina, right

eye H33.41

• Correct code:

• H33.41

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Case Scenario

• A 67-year old patient has had type 2

diabetes mellitus for 10 years • On insulin for blood sugar control for past 3 months

– Blood sugar doing well on insulin and diet

• Family doctor referred her to ophthalmologist with

suspected condition related to the diabetes

• Ophthalmologist examines patient and finds

diabetic retinopathy that is nonproliferative, with

macular edema – condition is moderate

– Physician recommends surgery same day


193

Case Scenario

• Alphabetic index: • Diabetes Type 2 diabetic retinopathy

nonproliferative moderate with macular

edema E11.331

• Tabular list: • E11.331 Type 2 diabetes mellitus with moderate

nonproliferative diabetic retinopathy with macular

edema (must use addt’l code to identify insulin use) – Z79.4 Long term insulin use

• Correct code sequence: • E11.331, Z79.4

194

Case Scenario

• A patient who had cataract surgery on the

right eye two days ago now experiencing

pain in right eye • Following a slit lamp exam of affected eye,

physician discovered lens fragments in right eye

– Returned patient to OR to remove fragments

• Alphabetic Index: • Complications Postprocedural Following

Cataract Surgery Cataract (lens) fragments

H59.02

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Case Scenario

• Tabular List:

• H59.021 - Cataract (lens) fragments in eye

following cataract surgery, right eye

• Correct Code Sequence:

• H59.021

• H57.11 – Ocular Pain

– Chapter 7 (Eye and Adnexa) includes instructional note to

use external cause code following code for eye condition,

if applicable, to identify cause of eye condition


196

Case Scenario

• 67 year old male jet skiing at South Beach – Was driving recklessly and fell off jet ski

• Hit in left eye with handle bar before entering water

– Does not recall accident and admits to

drinking too many beers before getting on jet

ski • Presented to office next day with complaint of eye

swelling when he blows his nose

• Diagnosed with orbital floor fracture

197

Case Scenario

• Alphabetic index: • Fracture, traumaticorbitfloor (blow out) – S02.3

• Tabular list: • S02.3 – Fracture of orbital floor

• Correct code sequence: • x7th - S02.3XXB – Fracture of orbital floor

– No 5th & 6th digits available

– “X” place holder must fill empty spaces

– “B” is 7th digit for initial encounter for open fracture

• V93.33XA – Fall on board jet ski – Injury also requires secondary code for external cause

– “X” is place holder – diagnosis requires 7 digits

– “A” is for initial encounter [for injury]

198

Overcome Obstacles

• Anticipate problems!

– Possible delays in payment from carriers until

everyone is fully trained

– Inaccurate coding, reporting, and processing

increasing delays in payment

• Denials, and/or rejections

• Biggest obstacle to overcome may be

resistance to change • May have some staff turnover during transition


Medicare Audit Contractor

Concerns

200

Code 99215

• Last October, Florida’s Recovery Audit

Contractor (RAC) requested permission

from CMS to start reviewing code 99215

– The review was to be limited to a small

number of providers with a high utilization of

code 99215

• However, if error rates are high, could lead to more

in-depth review on additional providers

– Conduct internal audits on your high level

E&M services

201

Legibility of Chart Entries

• Illegibility has become an even bigger

issue with CMS, MACs, RACs, and OIG

• Coverage policies specifically address

need for records to be legible

– Includes any copies scanned into EMR system

– If auditor can’t read chart, can render a service

non-covered or reduce the code

• Could result in refund requests and lost revenue


202

Physician Signatures

• Medicare requires physician providing

service be identified in the medical record

– Chart is usually signed at the bottom by

physician

• Signature attests that all the documentation is true

and accurate for service performed at that visit

– Stamped signatures are NEVER acceptable

203


• Electronic signatures – new challenge

– Samples of acceptable electronic signatures

include:

• Chart “Accepted by” with provider’s name

• “Electronically signed by” with provider’s name

• “Verified by” with provider’s name

• “Reviewed by” with provider’s name

• “Released by” with provider’s name

• “Signed before import by” with provider’s name

204


• Digitalized signature

– Handwritten and scanned into the computer

• “This is an electronically verified report by John

“Smith, M.D.”

• “Authenticated by John Smith, M.D.”

• “Authorized by John Smith, M.D.”

• “Digital Signature: John Smith, M.D.”

• “Confirmed by”: with provider’s name


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• “Closed by” with provider’s name

• “Finalized by” with provider’s name

• “Electronically approved by” with provider’s name

• Medicare contractors/carries have

published guidelines in their newsletters • Also available on MAC website

– If signature requirements not met CMS will

require attestation statement when submitting

medical records for review

206

Use of Scribes

• Medical record must be clear as to

physician who performed the service

• Use of scribe should be documented in

both paper chart and EMR

– “Scribed by M. Moore for John Smith, MD on

1/3/13”

• EMR log-in passwords should not be

shared with anyone else

207

Use of Scribes

• If technician is also the scribe

– Need statement by MD that information

obtained by technician was reviewed and

verified

• Exception: MD must personally obtain and

document or scribe the HPI when billing higher

level E&M services (99 codes)


208

Amending Medical Record

• Paper Charts

– Medicare expects to see:

– S.L.I.D.E.

• Single Line through error

• Initials of the person making the amendment

• Date the amendment is made

• Entry for correction

– White-out/obliteration of original entry not acceptable

209


• EMR

– Addendums

• Should be made in system where documentation

was originally created

• Make sure any addendums are forwarded to any

place where information has been previously sent

– Referring doctor for example

– Amendments

• Should be timely and bear the current date of

documentation

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– Corrections after final signature • Usually only one individual has ability to “unlock” a

document once it has been signed

• Corrections should be made in the system where

the document was created – Entries should be flagged as corrections and should be

carefully monitored and audited

• Current date and time should be entered

• Person making change should be identified

• Reason for correction should be noted in record


211


– Deletions

• If system allows “strike-through” lines, practice

should follow S.L.I.D.E guidelines

• Some systems may not permit deletions after

record is signed and considered “locked”

– May need to see how vendor and/or malpractice provider

wants you to handle deletions in EMR

– Create practice policy for future reference

• Total elimination of information should NEVER

occur

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– Late Entries

• Usually applies to physician orders, progress notes

or allied health assessments

• Varies by system

– Will need to work with vendor on how this can be done

– Establish practice policy for future reference

• The person making the late entry should document

within the entry that it is a “late” entry

213


• May want to create a practice policy for

time limits on late entries/corrections to

medical records

– (days/weeks/months)

• Audit for compliance


CMS SITE AUDITS

215

CMS Site Audits

• Clinic

– May get a site visit from CMS after filing

revalidation application

– Auditors taking pictures of building and

signage, state license, and requesting copies

of various documents

• Be sure to obtain a business card and look at the

CMS badge closely

• Don’t let the auditor intimidate you

216

CMS Site Audits

• Physicians and ASCs are considered

“limited risk” providers but doesn’t

guarantee you won’t get a site visit

– If the auditor asks to copy or remove records,

call your attorney

• Optical Shops

– Optical shops (DME) are considered high-risk

providers


217

CMS Site Audits

• Auditors are looking for such things as:

– Making sure hours of operation are posted

– You have a good inventory of Medicare

covered frames

– Patient is given a receipt for glasses ordered

– You have a method for patients to lodge

complaints

– Records are properly maintained in the optical

218

CMS Site Audits

– Patients have access to DME Supplier

Standards

• Recommend you go over the Suppliers Standards

to make sure you are in full compliance

COMPLIANCE ISSUES

Non-compliance Can Affect Reimbursement


220

Compliance

• Conduct internal audits routinely

• Have external audits conducted at least

every 2 years

– Audits can help guard against unnecessary

scrutiny by MACs, RACs, ZPICs, MICs, and

OIG

• Remember, compliance is a team effort!

221

Compliance

• Train staff well

• Conduct regular internal and external

audits regularly

• Require billing and coding staff to maintain

a high level of competency

– Coding Seminars

– Webinars

– On-line coding courses

222

Compliance

• Review all Medicare rejections and denials

when received

– Error-prone providers more likely to get

audited now

• If using billing service, monitor them just

like you would your own billing staff

– Billing services make errors too


223

Compliance

• Run procedure reports on modifiers used

most frequently

– Conduct internal audits to make sure

requirements are being met

• Hold in-services as needed if requirements

not met

– Include billers and coders as well as

technicians and nurses

• Remember, just because Medicare paid it doesn’t

mean it was paid appropriately

224

Compliance

• Modifiers are located in the back of the

CPT coding manual

– Make sure all billing and coding staff refers to

these modifiers regularly

• If in doubt whether a particular modifier is

needed, ask a supervisor for assistance

– Compliance is important for:

• Avoiding audits

• Getting paid appropriately

225

Consider Compliance Plan

• Compliance Plans will become mandatory

– CMS to determine implementation date and

timeline of core elements

• HHS published a model

– “Compliance Program Guidance for Individual

and Small Group Physician Practices”

– Includes 7 elements that can easily be

implemented yourself


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• Conducting internal monitoring and auditing;

• Implementing compliance and practice standards;

• Designating a compliance officer or contact;

• Conducting appropriate training and education;

• Responding appropriately to detected offenses and

developing corrective actions

• Enforcing disciplinary standards through well-

publicized guidelines

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• You don’t have to implement all 7

components of a full scale compliance

program

– These steps are geared toward implementing

a voluntary compliance program

• However, the more you work towards compliance,

the more prepared you will be when Compliance

Plans do become mandatory

Questions

Rose & Associates

1-800-720-9667

[email protected]

www.roseandassociates.com

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http://www.roseandassociates.com/

This program is sponsored by the

Florida Society of Ophthalmology

6816 Southpoint Parkway, Suite 1000 Jacksonville, FL 32216

Phone: 904-998-0819 Fax: 904-998-0855 www.ophmasters.com

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